Patients must have access to key pieces of information regarding prior authorization.

Under CMS-0057-F, patients must have access to their prior authorization data through their health plans. Payers are required to provide patients with a clear and timely view of their prior authorization status, including details on the request, approval, or denial. This access is facilitated through online portals or electronic health records systems, ensuring transparency and allowing patients to track the progress of their requests. The data should include information on the procedures, medications, or services involved, as well as any decisions made regarding coverage, to support patient engagement and informed decision-making.

Data Requirement Overview

Under the CMS Interoperability and Prior Authorization Final Rule, patients must have access to certain key pieces of information regarding prior authorization to ensure transparency and facilitate their understanding of their care. Specifically, patients should be able to access:

1. Prior Authorization Requirements: Information about which services or items require prior authorization and the criteria used to determine whether an authorization is needed.
2. Status of Requests: The current status of prior authorization requests, including whether they have been approved, denied, or are still under review.
3. Decision Rationale: The reasons for approval or denial of prior authorization requests, including any specific criteria or conditions that influenced the decision.
4. Effective Dates: Dates when the prior authorization is valid, including start and end dates.
5. Contact Information: Contact details for the payer or provider, which can be used for follow-up questions or appeals.

Providing patients with this information helps them understand their coverage and care options, reducing confusion and facilitating better management of their healthcare needs.

What Prior Authorization Data Must Be Provided to the Patient

Under the CMS Interoperability and Prior Authorization Final Rule, different entities have specific responsibilities for providing prior authorization data to the patient:

1. Payers (Health Insurance Companies)
   • Prior Authorization Requirements: Information about which services or items require prior authorization.
   • Status of Requests: Current status of prior authorization requests.
   • Decision Rationale: Reasons for approval or denial, including criteria used for the decision.
   • Effective Dates: Start and end dates for the authorization.
   • Contact Information: Details for follow-up or appeals.
2. Healthcare Providers
   • Prior Authorization Requirements: While providers may inform patients about the need for prior authorization, the detailed requirements are typically provided by the payer.
   • Status of Requests: Providers usually relay the status of prior authorization requests to patients, based on information received from the payer.
   • Decision Rationale: Providers may explain the decision to the patient, but the detailed rationale is typically provided by the payer.
   • Effective Dates: Providers communicate the authorization’s effective dates to the patient.
   • Contact Information: Providers can offer contact details for the payer or assist with follow-up as needed.

In summary, payers are primarily responsible for providing detailed prior authorization data, while healthcare providers communicate this information to patients based on the details provided by the payer.

How Must the Data be Provided and By Which Parties

Under the CMS Interoperability and Prior Authorization Final Rule, the following guidelines are set for how and when prior authorization data must be provided to the patient:

Payers

How to Provide Data To the Patient

Electronic Access: Payers must provide prior authorization data in a machine-readable format, typically accessible through online portals or electronic health record (EHR) systems. This allows patients to view their information via secure, digital platforms.

Written Communication: In addition to electronic access, payers may also provide written notifications or summaries upon request, particularly for patients who do not have digital access.

When to Provide Data TO The PatienT

Upon Request: Payers should provide prior authorization information promptly when requested by the patient or their representative.

Timely Updates: Payers must ensure that the status of prior authorization requests, decision rationales, and other relevant information is updated in real-time or within a reasonable timeframe.

Healthcare Providers

How to Provide Data to the Patient

Communication: Providers should communicate prior authorization information directly to the patient, either verbally during appointments or through secure patient portals. They should help patients understand the status and implications of the prior authorization.

Documentation: Providers may provide written summaries or documentation if required, summarizing the prior authorization status and details as communicated by the payer.

When to Provide Data To the Patient

As Soon as Possible: Providers should inform patients of the prior authorization status and any related information as soon as they receive it from the payer.

Follow-Up: Providers should follow up with patients as needed to ensure they understand the prior authorization process and next steps.

These requirements aim to ensure transparency and facilitate patient access to essential information regarding their care and coverage.

Payer Requirements for Patient Requests

Under the CMS Interoperability and Prior Authorization Final Rule, payers are required to provide:

1. Accessible Request Process:
   • Clear Instructions: Payers must provide clear, easy-to-understand instructions on how patients can request prior authorization. This information should be readily available through various channels, including websites, customer service representatives, and written materials.
   • Multiple Channels: The process should be accessible through multiple channels, such as online portals, phone, mail, or in-person options. This ensures that patients have options for requesting prior authorization based on their preferences and accessibility needs.
2. Standardized Forms
   • Uniform Forms: Payers must use standardized forms and formats for prior authorization requests to ensure consistency and ease of use. These forms should be designed to capture all necessary information efficiently.
3. Timely Assistance
   • Customer Support: Payers must provide timely assistance through customer service or support teams to help patients navigate the prior authorization request process. This includes addressing any questions or issues that arise during the request process.
4. Transparency
   • Process Transparency: Payers must ensure that patients are informed about the prior authorization process, including how long it will take, what information is required, and how to track the status of their requests.
5. Appeal Process
   • Appeals Information: Payers should also provide information on how patients can appeal a prior authorization decision if it is denied. This includes clear instructions on the steps to take and the timeframe for submitting an appeal.

These requirements are designed to make the prior authorization process more patient-friendly, ensuring that patients can easily understand and navigate the process to get the care they need.

Provider Requirements for Patient Requests

There are requirements for how healthcare providers must facilitate the process of making prior authorization requests for patients. While the specifics can vary, key requirements generally include:

1. Clear Communication
   • Informing Patients: Providers must inform patients when a prior authorization is required for a service or item and explain the process. This includes providing clear guidance on what is needed and how the process works.
2. Assistance with Requests
   • Support: Providers are expected to assist patients in initiating prior authorization requests. This includes helping patients understand what information is required and potentially assisting in the completion of forms or submissions.
   • Coordination: Providers should coordinate with payers to submit the necessary documentation and information on behalf of the patient, ensuring that the process is as smooth as possible.
3. Transparency
   • Status Updates: Providers must keep patients informed about the status of their prior authorization requests. This includes notifying patients of any updates, approvals, or denials as soon as they are received from the payer.
   • Documentation: Providers should maintain clear records of all communications and submissions related to the prior authorization process and make these records accessible to patients upon request.
4. Educational Resources
   • Guidance Materials: Providers should offer educational resources or guidance materials to help patients understand the prior authorization process, including what steps they need to take and what to expect.
5. Timely Action
   • Prompt Handling: Providers should handle prior authorization requests promptly and ensure that requests are submitted in a timely manner to avoid delays in care.

These requirements help ensure that patients receive the necessary support and information to navigate the prior authorization process effectively, ultimately improving their access to care.